A resident with chronic pain and respiratory failure received 10 times the ordered Morphine dose after a new concentrated formulation was dispensed and administered without proper reconciliation or transcription into the MAR. Facility nurses did not promptly notify the provider, and the NP who changed the order did not directly communicate the discontinuation of the prior Morphine order to the facility. The report also cites a deficiency involving insulin use for another resident.
A resident receiving IV Ertapenem had the order transcribed incorrectly as 1 gram instead of 500 mg, and the MAR showed the higher dose was administered for several days. Another resident with HF and CKD had a Bumetanide increase ordered for fluid overload, but the order was entered with a delayed start date and the resident missed 12 doses. The RN, physician, and DON/DNS acknowledged the transcription and administration errors.
A resident with DM received 50 units of Novolog instead of the ordered 50 units of Tresiba after an RN failed to verify the insulin type before administration. The MAR, progress notes, incident report, and staff interviews confirmed the medication error, and the resident was monitored for hypoglycemia afterward.
A nurse failed to verify a resident’s identity before preparing meds and allegedly gave insulin intended for another resident, along with attempting to administer two oral meds not ordered for the resident. The resident, who was cognitively intact and had no insulin order, reported that the nurse checked a BG, asked where to inject the insulin, and then attempted to give Keppra and a sodium tablet before realizing the identity mix-up. The nurse acknowledged relying on a first name heard in the room and using the other resident’s EMR and orders.
A resident received another resident’s meds after an agency RN gave the roommate’s insulin, antipsychotics, antidiabetic, benzodiazepine, anticonvulsant, antidepressants, laxative, and eye drops to the wrong person, even though the resident had already received scheduled AM meds from an MA. The resident became lethargic and unresponsive with hypoglycemia, low BP, and bradycardia, required Glucagon and EMS transfer, and was admitted to the hospital for monitoring.
Significant medication error with intramuscular antibiotic administration: A resident with CKD and a UTI had an order for IM Ertapenem for 5 days, but the MAR did not show one scheduled dose as given. Surveyors found two unopened doses in the med cart, and the RN acknowledged the missed sign-off while the DON could not explain how the ordered doses were administered if doses remained in the cart.
A resident with cardiomyopathy and atrial fibrillation had an order for metoprolol tartrate 25 mg BID to be held only if HR was below 55 bpm and the physician notified. MAR review showed multiple doses were held for HRs above the ordered parameter, and several held doses had no documented HR. An LPN acknowledged the doses were given outside the HR parameters, and the DON could not provide evidence the medication was administered as ordered.
A facility failed to keep residents free from significant med errors involving hospital transfer orders and MAR omissions. One resident continued receiving insulin glargine after it was ordered discontinued and did not receive cefpodoxime as ordered; another had a COPD maintenance inhaler omitted from the chart despite repeated pharmacy review; a third received furosemide at the wrong dose; and a fourth had multiple missed doses of Vascepa and a COPD inhaler without provider notification.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
A nurse’s transcription error led to a Farxiga order, intended for one resident, being entered into another resident’s chart, causing that resident—who had diagnoses including edema and hypokalemia—to receive Farxiga 5 mg daily for an extended period before the mistake was discovered. The issue came to light following a community complaint and was confirmed through record review, a Medication Error Form, staff statements, and an interview with the DON, all documenting that the incorrect medication was administered for many days.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.